Take Two M&Ms and Call Me In The Morning

“I shall please” is the literal translation of the word placebo.  In modern times a placebo is generally understood to be a therapy that is nothing more than an inactive substance (such as a sugar pill) given in place of a real treatment.

The placebo came into common use in the 18th century, apparently prescribed quite routinely in order to “please” rather than truly benefit the patient.  Don’t have the right snake oil to treat a particular problem?  Just pull a placebo out of your medical bag and the patient (and your pocketbook) will be adequately pleased.  Nowadays this seems like a dirty trick, but it was probably safer for patients to take placebos than the real poisons that posed as legitimate therapy of the time.

Over time, however, the placebo became something more than just a ploy to be hoisted on unwitting but paying customers of two centuries ago.  It turns out that if you provide a sugar pill to a suffering patient and tell him that this miracle cure will bring relief for his ailments, the patient stands a reasonably good chance of experiencing the desired outcome.  This “placebo effect” was discovered years ago and has been replicated in numerous studies.

Contrary to what many people think we don’t actually use placebos these days in the course of routine patient care*.  Purposefully deceiving a patient with a sham therapy is considered unethical and has been officially condemned by most medical governing bodies.  The only time we use placebos in the modern age is in the research setting.  To study the effects of a new medication the novel compound is usually pitted against an inert look-alike pill (the so-called “placebo-controlled trial”), the purpose of which is to provide both the treatment and non-treatment volunteers the same apparent therapy and thereby eliminate any psychological bias that might otherwise arise.

The key to the placebo, of course, is that the volunteers in the study don’t know that they’re on it.  Each participant is randomly assigned to receive either the study drug or placebo, and they never know if the pill they ingest is a potent medication or a sugar pill.  Somehow, just the possibility of being on a legitimate therapy is enough to trigger an effect in the patients on placebo.  How this works no one really knows, but it clearly evokes some relationship between a patient’s psychology and their physiology—the “mind-body” effect.

But what if we were to be more forthright with study volunteers?  What if we were to tell them that they are actually taking nothing more than a dummy pill?  Would there be any effect?

Up until recently most people would have said no. An interesting study was recently published that addressed this issue head-on.  Harvard researchers conducted a study in patients suffering irritable bowel syndrome (IBS) in which they compared placebo pills to no therapy at all, with the measured endpoint being abdominal pain (a common complaint with this malady).  The interesting thing about this study is that the placebo-treated volunteers were told from the start that they were taking nothing more than sugar pills.

According to the researchers, 59% of patients on placebo obtained relief compared with only 35% of volunteers on no treatment.  In a story on NPR one patient related her experience in the study:

Linda Buonanno was one of the placebo study volunteers. She's had IBS for 16 years, and when the researchers told her she was getting fake pills, she didn't think they would do anything. "I said, 'How in the world is that going to work?'" Buonanno says. "But they said, 'Well, it's mind over matter.' I said, 'Well, alright, let's see how good my mind is.'"

 

Buonanno apparently has a pretty good mind, placebo-wise.

Her cramps, bloating and diarrhea disappeared after just three days of taking two placebos twice a day. Three weeks later, when she ran out of placebo, she asked for more – as many in the study did. But the study was over, and she couldn't get any more official placebos.

"The symptoms came right back," Buonanno says. So she went to a health food store and bought some of her own placebos — herbal supplement pills.

"I stuck it in my head that this is really helping out the IBS, and I've gotten rid of, like, 70 percent of my (IBS) problems," she says.

So here’s my question: if the placebo effect doesn’t rely on deception, would there be any ethical reason why doctors shouldn’t give “open-label” placebo a try?  A patient with ongoing, poorly treated, and frustrating symptoms might be given a prescription for placebos with the clear understanding that the only active ingredient in the new pill is a healthy dose of positive thinking.

But why stop there?  Since placebo pills are nothing more than sugar, can’t the patient bypass the doctor and pharmacy altogether and, like Linda in the excerpt above, simply get some sugar pills on their own?  Even simpler, why not just go to the nearest convenience store and purchase a pack of small, round candies?  A bag of Skittles at one a day could get your through the month and would barely dent your prescription medication budget.  Plus, an accidental overdose of this particular class of drug will do no more than increase your risk of cavities.

Of course, the placebo effect tends to exert more benefit in illnesses that manifest in a more subjective nature: chronic pain, mood disorders, anxiety.  While I’ve never seen evidence of the placebo effect in the treatment of a urinary tract infection, for example, I don’t imagine that the mind of the sufferer has much to do with whether a bacterium swimming in your bladder lives or dies (sweetening up the urine with the sugar in the placebo pills might make the environment paradoxically even more hospitable to the lurking germ)—although who knows how much power a truly optimistic psyche may actually exert?

I can’t see myself tossing aside my prescription pad and reaching for a bag of M&Ms for my patients with chest pain or difficulty breathing (although this might prove to be a good way to dispose of my daughter’s leftover Halloween candy).  Still, information like this reminds us how important a patient’s state of mind is when dealing with the state of the body.

Modern drug therapy works by targeting specific physiological functions of the body.  Placebos work by offering the patient something to believe in.  We can apply the best of both by carefully selecting the right medication and taking time to impress on patients the importance of compliance with the treatment plan, including the need to alter their lifestyle to embrace healthier habits.  In return, we can promise them that our therapy will indeed “please” their bodies with good health and longevity.

And then maybe we can reward them with a couple of Skittles.

* It may not be entirely correct for me to say that the use of placebos is not a part of modern medical culture.  I would argue that most of the use of antibiotics in the outpatient setting is actually a form of placebo therapy, since most simple infections, particularly respiratory, are due to a viral rather than bacterial source.  The primary care community has strived hard over the years to educate the public to not expect an antibiotic every time a patient gets the sniffles, but despite this many people don’t feel satisfied with their visit to the acute care clinic unless they come away with a prescription.  This, in my view, falls clearly into the “I shall please” category.